CAD/CAM international magazine of digital dentistry No. 4, 2016

digital workflow case report | 27 CAD/CAM 4 2016 cannot be assumed to be a predictable technique, especially in sites of thin periodontal biotypes. Augmentation, including flap reflection and facial grafting,cansometimesbeadvantageous.Materi- als capable of supporting new hard (osteoconduc- tive) and soft tissue ingrowth and regeneration should be utilized in these cases. Valentini10 demonstrated aesthetic success of im- mediate implants in sites where bone grafting and collagen membranes were utilized at the time of extraction and implant placement. Soft tissue augmentation in relation to implant therapy, often accomplished with subepithelial connective tissue grafts, has been recommended toenhancethecosmeticappearance.11 Thetimein- volved in procuring and closing the soft tissue and its donor site, along with the increased morbidity associated with this step, may preclude its imple- mentation in therapy. Palatal anatomy may also preclude its use in certain situations. In patients with shallow palatal vaults, the proximity to neu- rovascular structures can prevent the procure- ment of soft tissue graft or minimize their di- mensions. Also, the increased operating time and morbidity associated with autogenous connective tissuegraftingcannotbeignored.Dermalallograft can, in appropriate situations, serve as a viable alternative. Soft tissue augmentation may still be desired, not only for esthetic reasons, but also to preserve marginal bone levels around implants. Formation of biologic width around implants is a physiological “must”. If needed, it will develop at the expense of the marginal bone. It has been demonstrated that implants with “thick” soft tis- sues maintain more coronal marginal bone levels compared to those with “thin” soft tissues.12 Der- mal allografts have been used to “thicken” soft tis- sues and eliminate autogenous soft tissue grafts. Consisting of collagen, these grafts may also serve as cell-occlusive membranes, serving the dual function of tissue-thickening agent and guided bone regeneration (GBR).13 Provisionalizingimmediateimplantsmayenhance esthetics.14-18 Preserving soft tissue levels and developing prosthetic emergent profiles can be more efficacious with a provisional crown versus a round, non-anatomically-shaped healing abut- ment. The retention of provisional restorations may also play a role in the success of therapy. Stability of the restoration and avoiding early removal can be critical for successful osseo- integration as well as not disturbing the initial soft tissue remodelling around the crown(s). Screw-retention,thoughmoretechnique-sensitive compared to cement-retained fabrication, allows for tightening of the temporary crowns and elim- ination of possible cement-associated, biologic complications.19 Case report The following case report (Figs. 1–22) demon- strates how a hopeless maxillary incisor is ex- tracted and replaced with an immediate implant simultaneous with tissue augmentation and im- mediate provisionalization. Following papilla-sparing, facial flap-reflection, tooth #9 (#21) was carefully extracted. The alveo- Fig. 7: The site is reopened for placement of the same bone graft was placed over the facial cortex and covered with a dermal allograft, which was adapted, via a tissue punch around a HealDesign EV. Fig. 8: The flap was then sutured securely around the healing abutment with resorbable sutures. Fig. 9: Radiograph showing implant and healing abutment in place. Fig. 10: A Temp Abutment EV 4.2 was modified and covered with opaque composite resin prior to addition of bis acryl and flowable composite resin. Fig. 11: The restoration was torqued to 15 Ncm and placed out of occlusal contact with the opposing mandibular teeth, and light contact with the adjacent teeth. Fig. 12: Provisional restoration ten days post-op. Fig. 13: Provisional restoration two months post-op. Fig. 7 Fig. 8 Fig. 9 Fig. 10 Fig. 11 Fig. 12 Fig. 13 42016

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